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Who gets coverage?

Who gets coverage?. THE HEALTH INSURANCE INDUSTRY VIEWPOINT. ONLY PARENTS WITH SICK CHILDREN WILL BUY COVERAGE. SO, IT’S TOO EXPENSIVE TO COVER OKLAHOMA NEWBORNS IN THE INDIVIDUAL MARKET. HOW MUCH ARE THEY PAYING IN CLAIMS? MEDICAL LOSS RATIO ARE THEY SOLVENT? RISK BASED CAPITAL RATIO.

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Who gets coverage?

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  1. Who gets coverage?

  2. THE HEALTH INSURANCE INDUSTRY VIEWPOINT ONLY PARENTS WITH SICK CHILDREN WILL BUY COVERAGE. SO, IT’S TOO EXPENSIVE TO COVER OKLAHOMA NEWBORNS IN THE INDIVIDUAL MARKET.

  3. HOW MUCH ARE THEY PAYING IN CLAIMS? MEDICAL LOSS RATIO ARE THEY SOLVENT? RISK BASED CAPITAL RATIO

  4. Medical Loss Ratio Total Claims Paid / Total Premiums Collected What percentage of earned premiums are paid out in medical claims

  5. Medical Loss Ratio If an insurance company collects $100 in earned premiums and pays out $70 in total claims, its medical loss ratio is 70%. $70/$100 = 70%

  6. Medical Loss Ratio - Current Law • Oklahoma Law = 65% • Federal Law = 80% • (85% for large group market)

  7. RISK BASED CAPITAL RATIO • A SOLVENCY TEST • THE MINIMUM AMOUNT OF CAPITAL APPROPRIATE TO PAY CLAIMS

  8. RISK BASED CAPITAL RATIO • NUMERATOR -- NET WORTH • (CAPITAL PLUS SURPLUS) • DENOMINATOR – ADJUSTED NET WORTH • ADJUSTED DOWNWARD BY VARIOUS RISKS – ASSET RISK, UNDERWRITING RISK, CREDIT RISK

  9. RISK BASED CAPITAL RATIO • NET WORTH/ADJUSTED NET WORTH • MINIMUM LEVEL – 200% • NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, MODEL ACT 315

  10. SHOULD WE COVER BABIES IN THEIR FIRST YEAR OF LIFE?

  11. THE HEALTH INSURANCE INDUSTRY VIEWPOINT ONLY PARENTS WITH SICK CHILDREN WILL BUY COVERAGE. SO, IT’S TOO EXPENSIVE TO COVER OKLAHOMANNEWBORNS IN THE INDIVIDUAL MARKET.

  12. HOW MANY BABIES? OKLAHOMA BIRTH 55,000 COVERED BY MEDICAID (64%) 35,200 COVERED BY GROUP INS 18,900 (extrapolation from Dept. of Health) UNINSURED OR SELF-PAY 900 NEWBORN BIRTHS

  13. WHAT DID THESE 900 BABIES COST? • FROM DEPARTMENT OF HEALTH, THE HOSPITAL CHARGES WERE $3.5 MILLION OR ABOUT $4,000 PER DELIVERY. • HOW MUCH DOES THIS INSURANCE INDUSTRY OWE OKLAHOMANS IN PREMIUM REBATES • $12 MILLION

  14. EXISTING COVERAGE • LOW-BIRTH WEIGHT BABIES • FOR BABIES WEIGHING LESS THAN 2 POUNDS, 10 OUNCES, MEDICAID PROVIDES COVERAGE REGARDLESS OF FAMILY INCOME. • UNDER FEDERAL LAW, UNINSURED BABIES WILL BE ELIGIBLE FOR LOW COST PLANS BY THE AGE OF 6 MONTHS. • (OKLAHOMA HAS RECEIVED $66 MILLION IN FEDERAL MONEY FOR THE HIGH RISK POOL)

  15. WHO IS EXCLUDED • PARENTS OF APPROXIMATELY 1,000 NEWBORNS (NOT LOW BIRTH WEIGHT) FOR THE FIRST SIX MONTHS OF LIFE. • APPROXIMATELY 5% WILL HAVE HIGH COST DELIVERY. • WHAT WOULD IT COST TO PROVIDE COVERAGE FOR THIS POPULATION.

  16. WHY WON’T THE INSURANCE INDUSTRY ANSWER THIS QUESTION?

  17. INDIVIDUAL MARKET – ACTUARIAL REVIEW • EXPECTED CLAIMS FOR OKLAHOMANS FROM BIRTH TO AGE 19 MINUS • EXPECTED CLAIMS FOR OKLAHOMANS FROM AGE 1 TO AGE 19 EQUALS • COST TO COVER OKLAHOMANS FROM BIRTH TO AGE 1

  18. INDIVIDUAL MARKETNEWBORNS • SUPPOSE, YOU HAVE THE FOLLOWING INFORMATION: • COST TO COVER INFANTS • MLR WELL BELOW FEDERAL REQUIREMENT • RBCR 4-5 TIMES ABOVE REGULATORY MINIMUMS • WITHOUT A WAIVER FROM FEDERAL LAW, YOU OWE ABOUT $12 MILLION IN REBATES TO OKLAHOMA POLICY HOLDERS. • WHAT DOES IT SAY ABOUT YOUR CORPORATE CULTURE TO EXCLUDE INFANTS?

  19. INDIVIDUAL MARKET – NEWBORNS IF INSURANCE FIRMS ARE REQUIRED TO COVER FROM BIRTH TO AGE 1, WHAT IMPACT WOULD THIS HAVE ON THEIR MEDICAL LOSS RATIOS? WOULD THIS GET THEM TO THE 80% REQUIREMENT?

  20. INDIVIDUAL MARKET – NEWBORNS IF INSURANCE FIRMS ARE REQUIRED TO COVER FROM BIRTH TO AGE 1, WHAT IMPACT WOULD THIS HAVE ON THEIR RISK BASED CAPITAL RATIOS? WOULD THEIR SOLVENCY BE JEOPARDIZED UNDER NAIC TEST?

  21. INDIVIDUAL MARKET – NEWBORNS • DOESN’T THE DEPARTMENT OF INSURANCE HAVE LEVERAGE THEY DID NOT USE? • USE OF BULLY PULPIT • PUBLIC ADVOCACY • REFUSAL TO REQUEST WAIVER FROM MLR • (THAT’S $12 MILLION CURRENTLY OWED TO OKLAHOMA POLICY HOLDERS) IS IT RIGHT TO MAKE A DEAL THAT LEAVES OUT BABIES?

  22. INDIVIDUAL MARKET – NEWBORNS WE DON’T KNOW WHAT HEALTH REFORM WILL LOOK LIKE OVER THE NEXT 3 YEARS, UNTIL FEDERAL LAW IS EITHER OVERTURNED OR IMPLEMENTED? WHY NOT COVER INFANTS FOR THIS 3 YEAR PERIOD AND JUST MONITOR THE IMPACT ON MLR AND RBCR?

  23. INDIVIDUAL MARKETNEWBORNS • SOME INSURERS WANT TO DO THE RIGHT THING "Insurers said…[w]e'llstay in the marketplace and offer the coverage, but only if our competitors do,' …But when everybody else started pulling out, it had a domino effect.” Robert Zirkelbach, America’s Health Insurance Plans http://insurancenewsnet.com/article.aspx?id=226607&type=newswires

  24. INDIVIDUAL MARKETNEWBORNS • WHAT THAT MEANS “WE’LL DO THE RIGHT THING IF YOU MAKE US.”

  25. INDIVIDUAL MARKETNEWBORNS • SO – LET’S MAKE THEM DO THE RIGHT THING. • THERE’S A SIMPLE SOLUTION THAT PROTECTS OKLAHOMA NEWBORNS • MANDATE COVERAGE!

  26. First, they came for the trade unionists, and I did not speak out because I was not a trade unionist. Then they came for the Jews, and I did not speak out because I was not a Jew. Then they came for me, and there was no one left to speak out for me. Martin Niemoller

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